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Intake Form

Thank you for choosing to work with me. This form helps me understand your needs and create a healing session that honors your body's wisdom.

All information is confidential and protected under HIPAA.

First name

Last name

Date

Preferred Name/Pronouns

Gender Identity

Email

Phone

Date of Birth

Month

Day

Year

Address

City

State

Zip

Emergency Contact

Phone

How did you hear about us?

HEALTH HISTORY

Current Primary Care Physician

Physician's Phone

Are you currently under medical care?

Yes

No

If yes, for what conditions(s)?

Current Medications/Supplements

Known Allergies (oils, lotions, scents, latex)

Please check any conditions you currently have or have had in the past:

OTHER

Cancer treatment (chemo/radiation)

Infectious disease

Other

Any conditions not listed or more detailed information

CURRENT EXPERIENCE

What brings you to bodywork at this time?

Primary areas of concern or discomfort

Pain level (0-10, with 10 bring most severe)

Describe your pain/discomfort (sharp, dull, burning, aching etc.)

When did this begin?

What makes it better?

What makes it worse?

LIFESTYLE & SELF-CARE

Occupation

Hours seated

Physical activities/exercise

Sleep quality:

Excellent

Good

Fair

Poor

Average hours per night

Stress level (0-10)

Daily Water Intake

Primary stressors

Previous bodywork experience (massage, craniosacral, acupuncture, etc.)

What was helpful?

What wasn't helpful?

TREATMENT PREFERENCES & BOUNDARIES

Areas you'd like me to focus on:

Areas you prefer I avoid or approach gently:

Temperature preferences:

Warm room

Cool room

No preference

Music preference:

Soft music

Silence

Nature Sounds

No preference

Scent sensitivity:

None

Mild

Significant

Communication preference during session:

Please check regularly

Minimal talking unless I speak first

I'll let you know if anything needs adjusting

TRAUMA-INFORMED CONSENT

Your safety and comfort are my highest priorities. Please know that:

• You have body autonomy and control over what happens during your session.

• You may pause, adjust, or end the session at any time for any reason

• You are always fully draped except for the area being worked on

• You may keep clothing on if that feels more comfortable

• I will ask for permission before working on certain areas (abdomen, chest, TMJ inter-oral work)

• You never need to explain or justify your boundaries

Are there any areas of your body you prefer I do not touch?

No restriction

Yes, please avoid _________________________________________________

Is there anything about your history or current experience that would help me create a safer, more supportive session for you?

SESSION GOALS & INTENTIONS

What are you hoping to experience or receive from our work together?

INFORMED CONSENT & POLICIES

I understand that:

Massage therapy is not a substitute for medical examination, diagnosis, or treatment. I am encouraged to see a physician for any physical or mental ailment I am aware of.

The massage therapist does not diagnose illness, disease, or other physical or mental disorders. As such, she does not prescribe medical treatment or pharmaceuticals, nor does she perform spinal manipulations.

Massage therapy is beneficial for stress reduction, relief from muscular tension, pain relief, improved circulation, and nervous system regulation.

I will communicate openly about my comfort level, pressure preferences, and any discomfort during the session.

I will update the therapist on any changes to my health status.

Session fees are due at time of service unless other arrangements have been made.

24-hour cancellation notice is required. Late cancellations or no-shows will be charged 50% of the session fee.

My health information is kept confidential in accordance with HIPAA regulations.

I have provided accurate health information to the best of my knowledge.

I have completed this form accurately and agree to the terms outlined above. By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Date and time

Month

Day

Year

Time

HoursMinutes

Signature

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